Reconstructing human contributions to accidents: the new view on error and performance
Reconstructing human contributions to accidents: the new view on error and performance
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DOI：
10.1016/s0022-4375(02)00032-4
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发表时间：
2002-09-01
影响因子：
4.1
通讯作者：
Dekker, SWA
中科院分区：
文献类型：
--
作者：
Dekker, SWA
问题：如何重建人类对事故的贡献？调查人员可以很容易地采取回顾性局外人的立场，回顾一系列似乎导致不可避免的结果的事件，并指出人们哪里出了问题。然而，这并不能解释太多，并且可能无助于防止复发。方法和结果：本文探讨了调查人员如何根据最近被称为人为错误的新观点来重建人在事故中所扮演的角色。新观点的承诺是将有争议的人类评估和行动带回到它们所属的事件流程中，并帮助它们产生，以了解为什么评估和行动对当时的人们有意义。本文的后半部分讨论了调查人员可以开始重建人们不断发展的心态的一种方法。对行业的影响：在一个大部分事故归因于人为错误的时代，了解人们为什么这样做至关重要，而不是判断他们没有做我们现在知道他们应该做的事情。本文通过提出一种方法，帮助调查人员避免事后诸葛亮的陷阱，通过该方法，调查人员可以开始了解人们的行为和评估在当时的实际意义。 (C) 2002 年国家安全委员会和 Elsevier Science Ltd. 保留所有权利。
Problem: How can human contributions to accidents be reconstructed? Investigators can easily take the position a of retrospective outsider, looking back on a sequence of events that seems to lead to an inevitable outcome, and pointing out where people went wrong. This does not explain much, however, and may not help prevent recurrence. Method and results: This paper examines how investigators can reconstruct the role that people contribute to accidents in light of what has recently become known as the new view of human error. The commitment of the new view is to move controversial human assessments and actions back into the flow of events of which they were part and which helped bring them forth, to see why assessments and actions made sense to people at the time. The second half of the paper addresses one way in which investigators can begin to reconstruct people's unfolding mindsets. Impact on industry: In an era where a large portion of accidents are attributed to human error, it is critical to understand why people did what they did, rather than judging them for not doing what we now know they should have done. This paper helps investigators avoid the traps of hindsight by presenting a method with which investigators can begin to see how people's actions and assessments actually made sense at the time. (C) 2002 National Safety Council and Elsevier Science Ltd. All rights reserved.